Management of Combined Phacolytic/Phacomorphic Glaucoma as a Complication of Nd:YAG Laser Peripheral Iridotomy in a Patient with Mature Cataract

1
Management of Combined Phacolytic/Phacomorphic
Glaucoma as a Complication of NdYAG Laser
Peripheral Iridotomy in a Patient with Mature
Cataract

• K. Camille DiMiceli, MD
• Herbert J. Ingraham, MD
• Department of Ophthalmology, Geisinger Health
  System
• Danville, PA
• Authors have no financial interest

2
Purpose/Methods

• To discuss the management of a complicated
  phacolytic/ phacomorphic glaucoma case incited by
  NdYAG laser peripheral iridotomy with accidental
  disruption of the anterior capsule.
• A retrospective study of the patients chart was
  performed as well as photo documentation. The
  patient was followed over the course of several
  weeks before and after cataract surgery.

3
Case Presentation

• An 87 year old female with a history of mature
  cataracts, narrow angle glaucoma, and chronic
  macular holes OU presents with severe right eye
  pain, nausea and vomiting.
• YagNd LPI was performed OD at an outside office
  for narrow angle one day prior. Leakage of white
  milky material was noted from LPI site post
  laser. Patient was referred to Geisinger for
  further management.

4
Exam

• AC OD very shallow crystalline material OS
  narrow angle
• Iris OU patent PI superiorly OD with white
  crystalline material
• Lens OD fluffy cortical material with
  4brunescent nucleus OS 4 brunescent cataract
• Fundus OU no view

• Va OD CF at ½ foot OS CF at 1 foot
• Pressure OD 62mmHg OS 8mmHg
• Pupils OD 3mm, fixed and mid-dilated, extensive
  synechiae OS 3mm reactive
• Conj 1 injection OU
• Cornea OD 1 edema OS clear

5
Pathophysiology

• Our patient had refused cataract surgery in the
  past because of multiple medical problems and
  poor visual prognosis secondary to bilateral
  chronic macular holes.
• The mature intumescent lenses that developed
  caused phacomorphic angle closure glaucoma.
• Traumatic rupture of the anterior capsule with
  YagNd laser released high molecular weight
  proteins, which blocked the trabecular meshwork
  and caused acute severe elevated IOP. (4,7)
• Macrophages are the main cellular component of
  the AC reaction that ensues upon release of the
  lens proteins. 7

6
Treatment

• Medical Therapy It is recommend to always
  attempt to lower IOP and allow time for
  inflammation to subside prior to lens removal.
  Our treatment consisted of the following
• Topical beta-adrenergic antagonist
• Oral carbonic anhydrase inhibitors
  (Acetazolamide) are faster and slightly more
  effective than topical agents. There is no
  additive effect of using the two together. When
  using Acetazolamide, the 250mg tabs act more
  quickly than 500mg sustained release caps.
• Aggressive topical steroids to quell inflammation
• Mydriatic v. Miotic We used Pilocarpine which
  took effect once the IOP was under better
  control. Miotics can theoretically worsen IOP by
  increasing pupillary block and anterior
  displacement of the lens-iris diaphragm.
  Mydriatics can worsen angle closure, but are
  helpful for use prior to surgery. There is no
  clinical difference when either agent is used. 5
• IV Mannitol is the next step, but was not
  necessary in our case.

7
Surgical Options

• Removal of the inciting lens and debris is the
  definitive treatment of lens induced glaucomas.
  We were able to stabilize the patient and manage
  medically for one week prior to surgery.
• ICCE was historically done to prevent
  phacoanaphylaxis, 1 but was replaced by ECCE as
  early as 1957.
• ECCE is the most commonly performed procedure.4
  Peripheral iridectomy is not necessary if a PCIOL
  is placed and there are no significant PAS. 5
• Phacoemulsification may be appropriate if the
  view is sufficient, if the zonules are secure,
  and the lens is not excessively dense.
• MSICS (manual small incision cataract surgery) is
  advocated as a safe, efficient and cost-effective
  treatment in developing countries. 8
• Spontaneous recovery uncommon, but reported in
  patient who refused surgery. 3

8
Surgery

• In our patient we chose to do ECCE with iris
  stretch based on the presence of the following
• An extremely dense mahogany nucleus
• Extensive synechiae from chronic angle closure
• Poorly dilating pupil
• Ruptured anterior capsule
• ECCE was performed on the fellow eye to treat the
  phacomorphic glaucoma.

9
Results

• Final Results on Travatan qhs OU
• OD BCVA 4/400 (large stage 4 macular hole) IOP
  12mmHg
• OS BCVA 20/50 (small stage 4 macular hole)
  IOP 12mmHg

10
Conclusions

• In lens induced glaucomas the preoperative IOPs
  are markedly elevated (generally 40mmHg and
  higher) and visual acuity can be quite poor
  (average HM-LP). 5
• Despite this dismal presentation, after lens
  extraction the IOP can be adequately controlled,
  often without medication, and the vision can be
  restored if there is no other significant ocular
  pathology.
• In the management of this case we systematically
  went through our armamentarium of medications to
  control IOP and inflammation prior to and in
  preparation for the definitive treatment of
  cataract extraction. When possible, medical
  therapy should be used to temporize this tenuous
  condition and to create a safer surgical
  environment.

11
References

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• 2. Epstein David. Diagnosis and Management of
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  vol 89, no. 3 pp 227-229.
• 3. Blaise P, Duchesne B, Guillaume S and Galand
  A. Spontaneous Recovery in Phacolytic
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